1639296197 NPI number — PEDIATRIC INTERIM CARE CENTER, THE NEWBORN NURSERY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639296197 NPI number — PEDIATRIC INTERIM CARE CENTER, THE NEWBORN NURSERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC INTERIM CARE CENTER, THE NEWBORN NURSERY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639296197
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
328 4TH AVENUE SOUTH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-852-5253
Provider Business Mailing Address Fax Number:
253-852-5728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
328 4TH AVENUE SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-852-5253
Provider Business Practice Location Address Fax Number:
253-852-5728
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DRENNEN
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
253-852-5253

Provider Taxonomy Codes

  • Taxonomy code: 3140N1450X , with the licence number:  601250502 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7042823 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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